When Post-Traumatic Stress Disorder is in the news, it is mostly because of the number of veterans suffering as a result of combat-related trauma. Victims of other kinds of trauma can also suffer from PTSD, though, and often do without realizing it. PTSD mirrors other mental illnesses such as depression and anxiety, and can also present as, “I feel fine,” when really the “feeling fine” rooted in numbness and avoidance.

I have PTSD as a result of sexual abuse that was perpetrated on me throughout my childhood. Child sexual abuse and sexual assault are very common crimes, yet they are so stigmatized that they receive very little attention in the media from a mental health perspective. It is easier to report on a brave soldier coming home from war with flashbacks of violence than it is to admit that there are a lot of men and women out there suffering from similarly troubling symptoms that relate to their abuse or assault.

Has a traumatic event or episode happened to you, or did you witness one?
The threat of death, serious injury, violence, or sexual assault are all considered traumatic events. Not everyone experiences and perceives an event the same way, so there is no concrete list of events that can cause traumatic responses. It depends on the individual. Witnessing these events can be traumatic too, as can having a close friend or relative who has endured a traumatic event.

Sometimes, victims don’t remember that they were exposed to a trauma. Traumatic memories are not processed and stored like regular memories. I didn’t realize I had been a victim of sexual abuse as a child until I was an adult. In hindsight, I had a lot of PTSD symptoms even before I knew what had happened to me.

Are you re-experiencing the traumatic event?
The most common and well-known ways of re-experiencing a traumatic event is through flashbacks, intrusive memories and nightmares. There are, however, ways of re-experiencing a trauma that do not involve memories, dreams, or visions of the event.

Before I realized the extent of what had happened to me, I was re-experiencing my trauma — I just didn’t know that I was. Many of the ways I re-experienced the trauma then was through body memories. I would become overwhelmed by a particular emotion or feeling in my body.

Until recently, I was not aware that I was re-experiencing my trauma and I did not know that I was feeling distress or overreacting to a situation because it reminded me in some way of my trauma. While I have flashbacks and nightmares, the primary way I re-experience my trauma is by feeling emotions and physical reactions in my body that do not make sense when I consider what is actually going on around me.

Do you avoid things that remind you of the trauma?
Trauma is scary and disruptive. It is natural to want to avoid situations that might remind us of unpleasant or threatening events. People with PTSD want to avoid places, activities, objects that bring up unpleasant reminders or feelings about the trauma.

People with PTSD tend to avoid thoughts or feelings that related to the trauma. For example, I try to avoid feeling startled, because the adrenaline rush and sudden jolt reminds me of times I wasn’t safe. So, while balloons popping have nothing to do with my abuse, the feeling the loud sound brings about does.

Is your memory out of whack? Is your mood off?
Feeling threatened and unsafe causes memories to be formed and stored differently than regular events. Sometimes victims dissociate, or “check out,” while the event is going on. Inability to access memories of the event is a feature of PTSD.

Likewise, negative beliefs about the world can be indicative of PTSD. For example, it is easy for me to believe that the world is unsafe and people should not be trusted. While there are many cynical people out there, my belief system is rooted in childhood trauma.

Blame, negative emotions (shame, fear, anger, guilt), lack of interest in activities that were enjoyable pre-trauma, isolation, and the in ability to experience positive emotions are also symptoms of PTSD.

These cognitive and emotional symptoms are among the most confusing and are the reason PTSD is often misdiagnosed. Think about it: You feel sad, don’t like to hang out with people, think the world is a bad place, and have few activities you actually like doing. Sounds like depression, right?

Do your reactions catch you off guard? Are you on high alert?
Engaging in destructive or self-injurious behavior are common in people with PTSD. Self-harm, for example, is a way many people cope with their past trauma. Other self-destructive behavior and addictions can be ways of dealing with the fallout as well.

Difficulty sleeping, feeling startled, always being on alert are also symptoms. When my PTSD was at its worst, I was very jumpy and uncomfortable around people. I was always on the lookout. I didn’t know what I was looking out for, but I felt very shifty and compelled to notice everything in my environment. I also had so much trouble concentrating that I would get confused about the day of the week, or my route back home if I left the house.

Feeling startled and jumpy can also be symptoms of anxiety, so that is a common misdiagnosis of PTSD, particularly when the person suffering from PTSD is presenting as more agitated than sad and dejected.

Does any of this sound familiar?
When I figured out I had PTSD, I was surprised. I thought I was doing really well for years and years. In hindsight, I was just numb and had a constricted range of feelings, also related to the trauma. Later, my PTSD presented with some of the more dramatic characteristics like flashbacks, nightmares, and extreme emotional reactivity.

It’s easy to explain away symptoms as more socially acceptable and common conditions. “Must be depression!” Or, “Oh, I guess I’ve always been hypersensitive.” Those statements are easier to say than, “I think I have PTSD.”

If you’ve been the victim of a traumatic event or episode and have assumed you are struggling with depression or anxiety, or, if you feel you are “over it,” but don’t feel much of anything when you really think about it, it might be worth familiarizing yourself with the symptoms of PTSD and get in touch with your doctor or a mental health professional who can help. The good news is, there are many effective treatments for PTSD that can improve the way you feel and function.

If you or someone you know has been affected by sexual violence, it’s not your fault. You are not alone. Help is available 24/7 through the National Sexual Assault Hotline: 800-656-HOPE and online.rainn.org, y en español: rainn.org/es.

Who cares? Or more appropriately, does the ruling elite and national media honestly give a damn about whether the warrior class receives the highest quality of treatment for war stress injuries available? Better yet, why should the 95.5 percent of the American public that has never deployed to a war zone, be the least bit concerned?

Aside from the obvious moral and ethical obligation to keep a sacred promise to care for those that we send to war, each year the number of veterans receiving mental health care has increased, from about 900,000 in fiscal year 2006 to about 1.2 million in fiscal year 2010 [1]. Research has consistently shown that after accounting for the intensity and duration of exposure to combat stress, the next best predictor of developing chronic war stress injuries such as PTSD, is the level of perceived social support [2]. Factor in the exorbitant individual and societal costs of untreated and inadequately treated war stress injuries, including the escalating rates of rage and despair directed inward (e.g., suicide), and outward (e.g., interpersonal violence), the hard truth after every war, is that one way or another, we all pay a very high cost, often decades after the war comes home.

In January 2004, the Department of Veterans Affairs (DVA) and Department of Defense (DoD), published the first-ever Clinical Practice Guideline for Management of Post-Traumatic Stress (DVA/DoD, 2004), listing Eye Movement Desensitization and Reprocessing (EMDR) therapy as one of only four, top-tier recommended evidence-based psychotherapies, concluding that:

• “Overall, argument can reasonably be made that there are sufficient controlled studies that have sufficient methodological integrity to judge EMDR as effective treatment for PTSD” (p. 5)
• “Foa et al (1995) note that exposure therapy may not be appropriate for use with clients whose primary symptoms include guilt, anger, or shame” (p. 4)
• “EMDR may be more easily tolerated for patients who have difficulties engaging in prolonged exposure therapy” (p. 2)
• “EMDR processing is internal to the patient, who does not have to reveal the traumatic event” (p. 1).

Justification for the DVA/DoD’s designation of EMDR as a highly recommended treatment, included a randomized controlled trial of EMDR in 1998 with Vietnam combat veterans demonstrating that 77 percent of veterans no longer had PTSD diagnosis after 12 sessions and with no drop-outs [3]. Promising results; however, 1998 marked the last EMDR research trial the DVA has funded. Subsequently, in February, 2004, the American Psychiatric Association released their PTSD treatment guidelines — similarly designating EMDR as evidence — based practice (see the Practice Guideline section below for further evidence of the domestic and international scientific communities position on EMDR).

Restricting Veteran’s Access to High Quality PTSD Treatments

However, in my last blog, “War Atrocities in Afghanistan: Who Is Blameworthy?,” I reported that in January 2011, the Government Accountability Office (GAO) investigated the DVA’s decision to severely restrict veterans’ access to only two PTSD treatments, both homegrown by DVA researchers — Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) — while excluding external competitors such as top ranked evidence-based PTSD treatments like Eye Movement Desensitization and Reprocessing (EMDR), developed outside the DVA. Aggravating the injustice, in February 2012, the DVA informs the Congressional Budget Office that 60 percent of VA patients fail to complete their PTSD treatment. In a field where there are no panaceas, veterans deserve access to all of the best available treatments, as reflexively promised by DVA, DoD, and government leaders.

Unveiling the VA’s Deception

Getting back to the 2011 GAO report, what I didn’t mention is that the GAO actually commented on how VA officials attempted to lie and cover-up their harmful policy to limit veteran’s access for PTSD treatment, by falsely stating their decisions were based on a 2008 DVA commissioned survey by the Institute of Medicine (IOM). The IOM report was uncharacteristically sloppy, and is the only domestic or international “expert panel” to ever deny EMDR’s status as evidence-based. However, the GAO openly questioned VA officials about the truthfulness of their account, citing documents showing that long prior to the IOM report, VA had already begun to invest significant resources in training programs and manuals for its politically favored CPT and PE treatments, while completely excluding EMDR.

Verification of the VA’s deception and playing politics with veteran’s mental health care is publicly accessible. For example, in 2007, the DVA hired the IOM under the guise “to assess the scientific evidence on treatment modalities for Posttraumatic Stress Disorder (PTSD)” despite the fact that the DVA’s and DoD’s own panel of experts, along with the American Psychiatric Association, had already done the same in 2004. On October 18, 2007, the very day that the IOM released its preliminary draft, Dr. Antonette Zeiss, VA’s Deputy Chief of Mental Health Services published an immediate News Release entitled, “VA Agrees with Key Points about PTSD Treatment In New Institute of Medicine Report.” Swiftly reacting to the draft IOM report, Dr. Zeiss announced that, “The report released today by the IOM Committee on Treatment of PTSD concluded among its key findings that exposure-based therapies such as prolonged exposure therapy and cognitive processing therapy have proven to be effective treatments for PTSD, while more research is needed on pharmacotherapy to determine its effectiveness.” The Deputy Chief adds that, “VA is pleased to see IOM agrees with us that exposure-based therapies are effective treatments for PTSD,” and then goes onto explain the reason behind the DVA’s satisfaction, is that the “VA has been making the therapies readily available, even before the IOM report was released.”

Jumping ahead, in 2010, the DVA/DoD practice guideline was updated, and reaffirmed EMDR as a top-rated PTSD treatment, thereby contradicting the 2008 IOM report, as has every PTSD practice guideline since.

Impunity of Institutional Military Medicine Politics and Veteran’s Mental Healthcare

On October 19, 2006, I testified on the “Status of DoD Mental Health Care: Carpe Diem,” before the congressional DoD Task Force in San Diego, California (Transcript available on Defense Health Board website). Amongst other pressing issues related to the military mental health care debacle mentioned earlier, the military’s institutional ban of EMDR training, treatment (TRICARE), and research was discussed, along with empirical evidence obtained from the field, clearly supporting EMDR’s potential effectiveness as described earlier. The testimony was covered by local (i.e., San Diego Union Tribune – “Military’s mental care ailing, panel is advised: Staff burnout, resource shortage cited by experts“) and national press (i.e., USA Today, “Navy Psychologist: Navy faces crisis“), that set-off another firestorm. Unfortunately, media portrayals narrowly focused on broader deficits (i.e., staffing shortages, inadequate training, etc.), and failed to specifically address the status of EMDR, or the underlying causes for the current and past failures to meet military mental health needs.

Sadly, but not unexpectedly, after a year-long tour of military bases, the DoD Task Force released its report in June 2007, concluding that, “The system of care for psychological health that has evolved over recent decades is insufficient to meet the needs of today’s forces and their beneficiaries, and will not be sufficient to meet their needs in the future,” and that, “the immediacy of these needs imparts a sense of urgency to this report” (see An Achievable Vision: Report of the Department of Defense Task Force on Mental Health-June 2007). The Task Force report listed “99” recommendations to fix serious, chronic mental health care deficits posing imminent harm to war veterans and their families (i.e., increasing staff, training, research, access to care, etc.). Specifically, in regards to clinical trainings and compliance with DVA/DoD clinical practice guidelines, the Task Force offered, “Recommendation 5.2.3.3. The Department of Defense should ensure that mental health professionals apply evidence-based clinical practice guidelines.” As for clinical research, the Task Force reported that “innovations in care often arise through research to understand the processes that generate need and efforts to develop and test new interventions.”

The Department of Defense (DoD) and EMDR Treatment Access

In comparison with the DVA, Military Medicine can claim the moral high ground, appearing considerably more enlightened with its decision to increase military patient access to all top rated PTSD treatments including EMDR, as it began to sponsor EMDR trainings in 2009, a mere eight years after the war started, and four years after I widely disseminated a 2005 clinical training survey. Knowing that military leaders respond best with data and proposed solutions versus a litany of complaints, and armed with the 2004 DVA/DoD PTSD treatment guidelines, I conducted what would become the first and only clinical training survey of military mental health clinicians. Tragically, the results of the convenience sample of 137 DoD mental health providers merely confirmed what every DoD clinician already instinctively knew-wherein 90 percent reported not receiving training or supervision on any of the four evidence-based PTSD treatments highly recommended by the DVA and DoD’s own clinical practice guidelines, including EMDR [4]. All of this of course was communicated to the aforementioned DoD Task Force.

Furthermore, on December 9, 2010, TRICARE, the military’s health care agency, quietly lifted its indefensible ban on covering EMDR therapy for military beneficiaries, posting, without explanation that “Eye Movement Desensitization and Reprocessing (EMDR) is now a TRICARE-covered benefit for the treatment of post-traumatic stress disorder (PTSD) in adults.” Tricare Management Activity’s decision to reverse its coverage of EMDR therapy represents Institutional Military Medicine’s begrudging acknowledgment that its exclusionary policy has been out of sync with the global scientific community and its own expert consensus since 2004. Most importantly, TRICARE’s course correction, finally grants access to an evidence-based treatment for military personnel, their family members, returning Reservists and National Guardsmen, and military retirees.

Despite significant evidence of leadership failures, public deception, and wrongful policies that potentially are harming thousands of veterans and their families, there has never been an investigation, ceremonial firings, media outrage, or congressional hearings as to “why” the nation has failed again to meet the mental health needs of the warrior class.

In Part-Two of this blog series, like a National Geographic exploration, we will uncover the amazingly bizarre, tragic, and mostly unknown world of PTSD research and military politics, and how both the DVA and DoD are engaging in a foolish conspiracy that will impact the future of military mental health care.

2. National Council for Mental Health: Bleich, A., Kotler, M., Kutz, L., Shaley, A. (2002). National Council for Mental Health: Guideline for the assessment and professional intervention with terror victims in the hospital and in the community. Jerusalem, Israel